International lower urinary tract function basic spinal cord injury data set

Changes in bladder emptying during inpatient rehabilitation after spinal cord injury and predicting factors: data from the Dutch Spinal Cord Injury Database

STUDY DESIGN

Secondary analysis of multicentre prospective observational data.

OBJECTIVES

To describe methods of bladder emptying at admission and discharge in patients with recently acquired spinal cord injury (SCI) and to describe predictors of bladder emptying methods at discharge.

SETTING

First inpatient rehabilitation in specialised rehabilitation centres in the Netherlands.

METHODS

Data from the Dutch Spinal Cord Injury Database collected between 2015 and 2019 were used. McNemar-Bowker test was used to evaluate if bladder emptying methods differed over time; One-Way ANOVA and Chi-Square tests to see if bladder emptying methods differed by demographic and injury-related characteristics. Binary logistic regression was used to predict the type of bladder emptying at discharge with demographic and injury-related characteristics measured at admission.

RESULTS

Of 1403 patients, 44.1% had cervical, 38.4% thoracic and 17.5% lumbosacral lesions at admission. AIS classification was mostly D (63.8%). The method of bladder emptying changed significantly (p < 0.001) from admission to discharge: decrease of clean intermittent assisted catheterisation (17.1% to 4.1%) and indwelling catheter (33.4% to 16.3%) and increase in clean intermittent self-catheterisation (CISC, 7.8% to 22.2%) and normal voiding (40.2% to 56.1%). Age, sex, SCI level, AIS classification and level of independence predicted the method of bladder emptying at discharge (all p < 0.001).

CONCLUSIONS

During first inpatient rehabilitation, the method of bladder emptying changed resulting in more patients discharged with normal voiding and CISC. Age, sex, SCI level, AIS classification and level of independence in self-care were all confirmed as factors playing a role in this change.

How to learn the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) content: Self-study through booklet is not enough

OBJECTIVE

To investigate the baseline knowledge of autonomic functions and specifically the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) among medical students and to present the effective methods in learning of the ISAFSCI.

DESIGN

Interventional training session.

SETTING

A tertiary hospital.

PARTICIPANTS

37 medical students.

INTERVENTIONS

Before training, a self-rating questionnaire including 24 concepts extracted from the ISAFSCI was administrated to the students. Then students were divided into two groups. One group (N = 19) had a one-hour ISAFSCI booklet self-study (BSS), while the other group (N = 18) received a one-hour lecture-based learning (LBL) about the ISAFSCI. After BSS/LBL, all students were examined by a 15-question written test on the knowledge of ISAFSCI.

MAIN OUTCOME MEASURES

Baseline knowledge self-rating questionnaire before training and comparison of post-training performance on the written test between the BSS and LBL groups.

RESULTS

Before training, students were familiar with only 8 out of the 24 concepts within the questionnaire (demonstrating baseline knowledge rate beyond 50%). Significant difference in post-training performance (P<0.05) between BBS and LBL groups was noted for 5 of 15 items tested, including hypohydrosis, broncho-pulmonary system, lower urinary tract function, bowel function and female sexual function. All questions except the one regarding hypohydrosis were answered with greater than 80% accuracy by LBL group.

CONCLUSION

Use of ISAFSCI booklet alone for self-study by medical students is not sufficient to obtain bassline knowledge of autonomic discussions after SCI. It is recommended that formal lecture or presentation should be used to improve the effectiveness of learning the ISAFSCI for medical students.

Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study

BACKGROUND

Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls.

OBJECTIVE

To evaluate outcomes through 24 months postimplantation.

METHODS

INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury.

RESULTS

Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported.

CONCLUSION

In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.

Urological Management at Discharge from Acute Spinal Cord Injury Rehabilitation: A Descriptive Analysis from a Population-based Prospective Cohort

Background

There is limited epidemiological evidence describing contemporary neuro-urological management of persons with acute spinal cord injury (SCI).

Objective

To describe neurogenic lower urinary tract dysfunction (NLUTD) management at discharge from SCI rehabilitation.

Design, setting, and participants

The population-based Swiss Spinal Cord Injury (SwiSCI) cohort study prospectively collected data from 602 adults undergoing specialized postacute SCI rehabilitation from 2013 to 2020. The management strategy was based on the European Association of Urology (EAU) Guidelines on Neuro-Urology.

Outcome measurements and statistical analysis

Data were collected at discharge using the International SCI Lower Urinary Tract Function Basic Data Set. Multivariable logistic regression adjusting for demographics, SCI characteristics, and center, with inverse probability weighting accounting for sampling bias, was used to produce prevalence estimates and identify predictors of lower urinary tract symptoms (LUTS) and NLUTD management outcomes.

Results and limitations

At discharge (median time after SCI: 5.0 mo [Q1-Q3: 3.0–7.2]), the prevalence of LUTS or managed NLUTD was 82% (95% confidence interval [CI]: 79–85%). SCI completeness was the main predictor of LUTS and managed NLUTD. The risk of urinary incontinence was elevated in females (odds ratio 1.98 [95% CI: 1.18–3.32]) and with complete lesions (odds ratio 4.71 [95% CI: 2.52–8.81]). Voiding dysfunction was most commonly managed with intermittent catheterization (prevalence 39% [95% CI: 35–42%]), followed by indwelling catheterization (prevalence 22% [95% CI: 18–25%]). The prevalence of antimuscarinic or mirabegron use was 29% (95% CI: 26–33%). Urodynamic and renal function data were not collected.

Conclusions

Our population-based description of urological management in Swiss SCI centers utilizing the EAU Guidelines on Neuro-Urology may be used as a reference for evaluation in other settings. Data further indicate a need for sex-specific neuro-urological management research.

Patient summary

At discharge from spinal cord injury (SCI) rehabilitation, a majority of patients have lower urinary tract problems, especially those with complete SCI. Women have a higher risk of urinary incontinence.

Phase 1 Safety Trial of Autologous Human Schwann Cell Transplantation in Chronic Spinal Cord Injury

A phase 1 open-label, non-randomized clinical trial was conducted to determine feasibility and safety of autologous human Schwann cell (ahSC) transplantation accompanied by rehabilitation in participants with chronic spinal cord injury (SCI). Magnetic resonance imaging (MRI) was used to screen eligible participants to estimate an individualized volume of cell suspension to be implanted. The trial incorporated standardized multi-modal rehabilitation before and after cell delivery. Participants underwent sural nerve harvest, and ahSCs were isolated and propagated in culture. The dose of culture-expanded ahSCs injected into the chronic spinal cord lesion of each individual followed a cavity-filling volume approach. Primary outcome measures for safety and trend-toward efficacy were assessed. Two participants with American Spinal Injury Association Impairment Scale (AIS) A and two participants with incomplete chronic SCI (AIS B, C) were each enrolled in cervical and thoracic SCI cohorts (n = 8 total). All participants completed the study per protocol, and no serious adverse events related to sural nerve harvest or ahSC transplantation were reported. Urinary tract infections and skin abrasions were the most common adverse events reported. One participant experienced a 4-point improvement in motor function, a 6-point improvement in sensory function, and a 1-level improvement in neurological level of injury. Follow-up MRI in the cervical (6 months) and thoracic (24 months) cohorts revealed a reduction in cyst volume after transplantation with reduced effect over time. This phase 1 trial demonstrated the feasibility and safety of ahSC transplantation combined with a multi-modal rehabilitation protocol for participants with chronic SCI.

Reliability of the Urinary Symptom Questionnaires for people with neurogenic bladder (USQNB) who void or use indwelling catheters

STUDY DESIGN

This is a descriptive psychometrics study.

OBJECTIVES

Neurogenic lower urinary tract dysfunction (NLUTD), also called Neurogenic Bladder (NB), is a common and disruptive condition in a variety of neurologic diagnoses. Our team developed patient-centered instruments, Urinary Symptom Questionnaires for people with neurogenic bladder (USQNB), specific to people with NLUTD who manage their bladders with intermittent catheterization (IC), indwelling catheters (IDC), or who void (V). This article reports evidence of reliability of the IDC and V instruments.

SETTING

Online surveys completed by individuals in the United States with NLUTD due to spinal cord injury (SCI), or multiple sclerosis (MS) who manage their bladder with IDC (SCI, n = 306), or by voiding (SCI, n = 103; MS, n = 383).

METHODS

Reliability estimates were based on endorsement of the items on the USQNB-IDC and USQNB-V. Reliability evidence was representativeness of these symptoms for a national sample (by determining if endorsement > 10%); internal consistency estimates (by Cronbach's alpha and item correlation coefficient, ICC); and interrelatedness of the items (by inferred Bayesian network, BN). We also tested whether a one-factor conceptualization of "urinary symptoms in NLUTD" was supportable for either instrument.

RESULTS

All items were endorsed by >20% of our samples. Urine quality symptoms tended to be the most commonly endorsed on both instruments. Cronbach's alpha and ICC estimates were high (>0.74), but not suggestive of redundancy. BNs showed interpretable associations among the items, and did not discover uninterpretable or unexpected associations. Neither instrument fit a one-factor model, as expected.

CONCLUSIONS

The USQNB-IDC and USQNB-V instruments show sufficient, multidimensional reliability for implementation and further study.

Community dwelling life- and health issues among persons living with chronic spinal cord injury in North Macedonia

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

The purpose was to reveal late health consequences and life issues after a traumatic spinal cord injury (tSCI) in North Macedonia (NM).

SETTING

Community dwelling adults with tSCI in NM.

METHODS

Persons that sustained tSCI in 1999-2005 were selected, physical examined and a questionnaire was administered. Descriptive statistics were conducted.

RESULTS

From 203 eligible persons, 40 agreed to participate. Mean (range) age at time of injury was 36 (27-75) years and time since injury ranged 9-20 years. Around seventy percent reported current health problems, of which pain and spasm (>60%) were most prevalent, followed by urinary tract infections and pressure injuries. About 30% had never been to a medical specialist and ≈70% had only once been to physiotherapy after discharge from the primary inpatient period. Only one participant had a fully adjusted home for a person with a disability. Those with most severe tSCI (American Spinal Injury Association Impairment Scale (AIS) A, B, and C) seldom left their homes. About 50% were retired and/or unemployed, 50% were working.

CONCLUSION

This is the first study describing community-dwelling persons with a tSCI in NM. Our study revealed that persons with tSCI reported health issues mostly related to pain, spasms, urinary tract infections and pressure injuries. They lacked follow-ups, experienced physical barriers and poor inclusion in the society, and lacked financial support. Therefore, they were often socially isolated and fully dependent on their families. NM is in need of structured rehabilitation programs and better adaption for persons with reduced mobility.

Pulse article: survey of neurogenic bladder management in spinal cord injury patients around the world

STUDY DESIGN

Online survey distributed to healthcare professionals (HCPs) involved in care of spinal cord injury (SCI) patients with neurogenic lower urinary tract dysfunction (NLUTD).

OBJECTIVES

Identify and bring awareness to the variation of neurogenic bladder management in around the world.

SETTING

International online questionnaire.

METHODS

A 32-question survey was drafted and circulated among a global network of SCI experts for review. The survey was disseminated to healthcare professionals involved in the care of NLUTD in SCI patients via social media, grassroots methods, and international societies. The survey was available for 6 weeks and respondents answered questions regarding SCI population demographics, access to care, common neurogenic bladder management, diagnostic and imaging methods, complications, and follow up.

RESULTS

A total of 296 healthcare professionals, 132 from North America, 87 from Europe, 27 from Asia, 24 from Australia, 14 from South America, and 6 from Africa, responded to the survey. Global concurrence was noted among management method for patients without adequate hand function, first-line treatment for neurogenic detrusor overactivity, and common complications. Continents highly differed in responses regarding management method for patients with adequate hand function, frequency of patients reusing catheters, timing of urodynamics, and duration of antibiotic therapy for urinary tract infections.

CONCLUSIONS

The results of this international survey demonstrate the variability and uniqueness in neurogenic bladder management in SCI patients around the world. Increased international discourse and education will improve global communication and transparency with the efforts of reducing discrepancies in care.

Effects of Bilateral Transcutaneous Tibial Nerve Stimulation on Neurogenic Detrusor Overactivity in Spinal Cord Injury: A Urodynamic Study

OBJECTIVE

To study the short-term effect of bilateral transcutaneous tibial nerve stimulation (TTNS) on urodynamic study (UDM) parameters in spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO).

DESIGN

Single-blinded sham-controlled study.

SETTING

Rehabilitation center.

PARTICIPANTS

SCI patients with NDO (N=17) were recruited. Fifteen patients (mean age, 40±18y) completed the study. Most of the patients had chronic incomplete SCI.

INTERVENTIONS

UDM was performed 3 times. The first UDM was performed after taking anticholinergics for 1 hour to assess the effects of medication. After stopping anticholinergics for a 5 half-lives, the second UDM was performed immediately after a 20-minute sham TTNS (switch on for 30s at the beginning, switch off for 20min, and switch on for 30s before stopping). The third UDM was performed immediately after a 20-minute bilateral TTNS.

MAIN OUTCOME MEASURES

Reflex volume (mL), cystometric capacity (mL), maximum pressure detrusor (mmH₂O), and bladder compliance (mL/mmH₂O).

RESULTS

UDM tracings were interpreted by 2 blinded assessors. This study used per-protocol analysis and repeated measures Analysis of variance with Bonferroni post hoc analysis. When compared with sham stimulation, bilateral TTNS and anticholinergics produced greater increases in reflex volume (136.1±99.88, 212.2±112.82, and 226.3±111.52 mL; P<.001), cystometric capacity (218.3±137.66, 319.1±143.74, and 350.7±163.43 mL; P<.001), and compliance (5.8±6.81, 7.9±6.74, 9.7±8.12 mL/cmH₂O; P=.02). No significant differences were found in reflex volume, cystometric capacity, or compliance between bilateral TTNS and anticholinergics (P>.05). The maximum pressure detrusor was not significantly different between groups (P>.05).

CONCLUSION

Bilateral TTNS may be an effective short-term intervention to improve UDM parameters in SCI with NDO. Further study is necessary to determine the long-term effects and benefits of combined bilateral TTNS with anticholinergics.

Optimizing clinical trial design using prospective cohort study data: a case study in neuro-urology

Study Design

Simulations using data from a prospective cohort study.

Objectives

To illustrate how prospective cohort data can be employed in randomized controlled trial (RCT) planning to assess feasibility and operational challenges, using TASCI (Transcutaneous tibial nerve stimulation in patients with Acute Spinal Cord Injury to prevent neurogenic detrusor overactivity: a nationwide randomized, sham-controlled, double-blind clinical trial) as a case study.

Setting

Spinal cord injury rehabilitation centers in Switzerland.

Methods

TASCI is nested in the multicenter Swiss Spinal Cord Injury Cohort Study (SwiSCI), which prospectively includes patients with acute spinal cord injury. In simulations, data from 640 patients, collected by SwiSCI, were used to investigate different scenarios of patient eligibility and study consent, as well as the performance of the randomization list. Descriptive analysis was used to describe the population of interest and the simulation results; multivariable logistic regression analysis was performed to identify predictors of discharge within the TASCI intervention time period.

Results

The recruitment target of 114 patients is obtainable within the originally envisioned three-year time period under the most favorable recruitment scenario examined. The distribution of the primary prognostic factor produced imbalance in the randomization lists and informed further discussion of the cut-off values used in stratification. Influxes of patients resulted in overlapping intervention periods for multiple participants, which guided resource allocation. Early discharge was related to the primary prognostic factor and study center, but is only anticipated in about 8% of participants.

Conclusions

Prospective cohort data are a very valuable resource for planning RCTs.

Bladder and Bowel Management in Dogs With Spinal Cord Injury

Spinal cord injury in companion dogs can lead to urinary and fecal incontinence or retention, depending on the severity, and localization of the lesion along the canine nervous system. The bladder and gastrointestinal dysfunction caused by lesions of the autonomic system can be difficult to recognize, interpret and are easily overlooked. Nevertheless, it is crucial to maintain a high degree of awareness of the impact of micturition and defecation disturbances on the animal's condition, welfare and on the owner. The management of these disabilities is all the more challenging that the autonomic nervous system physiology is a complex topic. In this review, we propose to briefly remind the reader the physiology of micturition and defecation in dogs. We then present the bladder and gastrointestinal clinical signs associated with sacral lesions (i.e., the L7-S3 spinal cord segments and nerves) and supra-sacral lesions (i.e., cranial to the L7 spinal cord segment), largely in the context of intervertebral disc herniation. We summarize what is known about the natural recovery of urinary and fecal continence in dogs after spinal cord injury. In particular we review the incidence of urinary tract infection after injury. We finally explore the past and recent literature describing management of urinary and fecal dysfunction in the acute and chronic phase of spinal cord injury. This comprises medical therapies but importantly a number of surgical options, some known for decades such as sacral nerve stimulation, that might spark some interest in the field of spinal cord injury in companion dogs.

The data set development for the National Spinal Cord Injury Registry of Iran (NSCIR-IR): progress toward improving the quality of care

STUDY DESIGN

Descriptive study.

OBJECTIVES

The aim of this manuscript is to describe the development process of the data set for the National Spinal Cord Injury Registry of Iran (NSCIR-IR).

SETTING

SCI community in Iran.

METHODS

The NSCIR-IR data set was developed in 8 months, from March 2015 to October 2015. An expert panel of 14 members was formed. After a review of data sets of similar registries in developed countries, the selection and modification of the basic framework were performed over 16 meetings, based on the objectives and feasibility of the registry.

RESULTS

The final version of the data set was composed of 376 data elements including sociodemographic, hospital admission, injury incidence, prehospital procedures, emergency department visit, medical history, vertebral injury, spinal cord injury details, interventions, complications, and discharge data. It also includes 163 components of the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) and 65 data elements related to quality of life, pressure ulcers, pain, and spasticity.

CONCLUSION

The NSCIR-IR data set was developed in order to meet the quality improvement objectives of the registry. The process was centered around choosing the data elements assessing care provided to individuals in the acute and chronic phases of SCI in hospital settings. The International Spinal Cord Injury Data Set was selected as a basic framework, helped by comparison with data from other countries. Expert panel modifications facilitated the implementation of the registry process with the current clinical workflow in hospitals.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Long term continuation with repeated Botulinum toxin A injections in people with neurogenic detrusor overactivity after spinal cord injury

STUDY DESIGN

Retrospective chart study.

OBJECTIVES

The aim was to examine continuation of treatment of individuals with spinal cord injury including myelomeningocele and neurogenic detrusor overactivity, treated with repeated intra-detrusor Botulinum toxin A injections, and to investigate factors associated with discontinuation of treatment.

SETTING

Rigshospitalet, Denmark METHODS: This study included 128 individuals with spinal cord injury and neurogenic detrusor overactivity, who were offered repeated Botulinum toxin A injections between 2001 and 2018. Continuation rates of the treatment were estimated using Kaplan Meier analysis. A Cox proportional hazard analysis was used to investigate factors predictive of discontinuation.

RESULTS

A total of 1156 treatments were performed. The median number of treatments was six (IQR 9, range 1-51), and median follow-up was 10.6 years (IQR 8.5, range 0-16.9). All urodynamic parameters changed significantly after the first treatment (p < 0.001). The continuation group had significantly higher mean maximum bladder capacity after the first injections compared with the discontinuation group, with a mean difference between the groups of 84.5 mL (95% CI 4.7-164.2) (p = 0.038). The probability of continuing treatments after 5 years was 59% (95% CI 50.0-67.8) and 50% (95% CI 40.1-59.3) after 10 years. Individuals aged 31-50 years were more likely to continue treatment compared with those aged >50 years (95% CI 0.21‒0.79) (p = 0.008). No other factors predicted discontinuation.

CONCLUSIONS

This long-term follow-up study showed that 50% of people with spinal cord injury starting intra-detrusor Botulinum toxin A for neurogenic detrusor overactivity are still receiving injections after 10 years.

Fecal Incontinence and Neurogenic Bowel Dysfunction in Women With Traumatic and Nontraumatic Spinal Cord Injury

BACKGROUND

In the literature on chronic spinal cord injury, neurogenic bowel dysfunction has not gained as much attention as bladder dysfunction, the traditional cause of morbidity and mortality.

OBJECTIVE

The purpose of this study was to investigate the prevalence of fecal incontinence and conditions associated with fecal incontinence in women with spinal cord injury.

DESIGN

In this cross-sectional study, data were obtained from an electronic medical chart database containing standardized questionnaires.

SETTINGS

The study was conducted at the Clinic for Spinal Cord Injuries, Rigshospitalet, where patients from Eastern Denmark are followed every second year.

PATIENTS

Women who sustained a spinal cord injury between September 1999 and August 2016 and attended a consultation between August 2010 and August 2016 were included. If the bowel function questionnaire had never been answered, the woman was excluded.

MAIN OUTCOME MEASURES

The newest completed questionnaire regarding bowel function, urinary bladder function, quality of life, neurologic level/completeness/etiology of injury, mobility status, and spousal relationship was obtained from each woman.

RESULTS

Among the 733 identified women, 684 were included, of whom only 11% had a complete motor injury. A total of 35% experienced fecal incontinence, varying from daily to less than monthly, and 79% experienced bowel dysfunction. Fecal incontinence was associated with urinary incontinence and decreased satisfaction with life in general and psychological health. In the multivariate logistic regression analysis, the odds of daily-monthly fecal incontinence increased significantly with increasing age, myelomeningocele as etiology of injury, a more complete paraplegic injury, use of wheelchair permanently, and follow-up <3 months.

LIMITATIONS

There were missing data in the study, including 12% with no answer to the fecal incontinence question.

CONCLUSIONS

Fecal incontinence is a severe problem that affects more than one third of women with spinal cord injury and is associated with decreased quality of life. The present study emphasizes that women with myelomeningocele, a more complete paraplegic injury, older age, short follow-up period, and permanent wheelchair use have an increased risk of fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A985. INCONTINENCIA FECAL Y DISFUNCIÓN NEUROGÉNICA DEL INTESTINO EN MUJERES CON LESIÓN DE LA MEDULA ESPINAL TRAUMÁTICA Y NO TRAUMÁTICA: En la literatura sobre la lesión crónica de la médula espinal, la disfunción neurógena del intestino no ha ganado tanta atención como la disfunción de la vejiga, la causa tradicional de morbilidad y mortalidad. OBJETIVÓ:: Investigar la prevalencia de la incontinencia fecal y las condiciones asociadas con la incontinencia fecal en mujeres con lesión de la médula espinal. DISEÑO:: En este estudio transversal, los datos se obtuvieron de una base de datos de registros médicos electrónicos que contenía cuestionarios estandarizados. CONFIGURACIÓN:: Clínica para Lesiones de la Médula Espinal, Rigshospitalet, donde los pacientes del Este de Dinamarca son seguidos cada dos años.

PACIENTES

Mujeres que sufrieron una lesión en la médula espinal entre Septiembre de 1999 a Agosto de 2016 y asistieron a una consulta entre Agosto de 2010 a Agosto de 2016. Si nunca se había respondido el cuestionario de la función intestinal, se excluyó a la mujer.

MEDIDA DE RESULTADOS PRINCIPALES

Se obtuvo el cuestionario más reciente y completo sobre la función intestinal, la función de la vejiga urinaria, la calidad de vida, el nivel neurológico/integridad/etiología de la lesión, el estado de movilidad y la relación con el cónyuge.

RESULTADOS

Entre las 733 mujeres identificadas, se incluyeron 684, de las cuales solo el 11% tenía una lesión de motor completa. Un total de 35% experimentó incontinencia fecal que varió de diaria a menos de mensual, y el 79% experimentó disfunción intestinal. La incontinencia fecal se asoció con incontinencia urinaria y disminución de la satisfacción de vida en general y con la salud psicológica. En el análisis de regresión logística multivariable, las probabilidades de incontinencia fecal diaria-mensual aumentaron significativamente con el aumento de la edad, el mielomeningocele como etiología de la lesión, una lesión parapléjica más completa, el uso de silla de ruedas de forma permanente y el seguimiento <3 meses.

LIMITACIONES

Faltaban datos en el estudio, incluyendo el 12% sin respuesta a la pregunta sobre incontinencia fecal.

CONCLUSIONES

La incontinencia fecal es un problema grave que afecta a más de un tercio de las mujeres con lesión de la médula espinal y se asocia con una disminución de calidad de vida. El presente estudio enfatiza que las mujeres con mielomeningocele, una lesión parapléjica más completa, mayor edad, corto período de seguimiento y uso de silla de ruedas permanente tienen un mayor riesgo de incontinencia fecal. Vea el Video del Resumen en http://links.lww.com/DCR/A985.

Cross-sectional and prospective data-collection in North Macedonia-methodological considerations

Study design

Cross-sectional and prospective cohort-study.

Objectives

To describe methodological issues, experienced challenges related to data collection in North Macedonia and to discuss possible improvements of epidemiological data collection in future studies.

Setting

Clinic for Traumatology, Orthopedics, Anesthesia, Reanimation, Intensive Care Unit and Emergency Center, Mother Teresa Skopje University Hospital, Skopje and community settings, North Macedonia.

Method

A description of methodological challenges experienced in collecting data from 78 persons with acute and chronic traumatic spinal cord injury (SCI) examined and interviewed in 2015-2017 using a semiquantitative questionnaire and standard assessments tools.

Results

This study identified three major challenges with data collection in this setting: (1) research logistics and procedures, such as recruitment, infrastructure, and compensation, (2) ethical issues and the initial lack of mutual trust and understanding between researchers and participants, and (3) scientific quality and interpretation, including representativeness.

Conclusions

Methodological issues influenced by settings, are important to consider when interpreting study results. Healthcare systems vary between (and sometimes in) countries, language and culture may introduce barriers to understanding, and epidemiological research also rely on infrastructure and surroundings. For this study, making time for and listening to the participants without being intruding was of special importance in building trust and a good relationship with the participants during recruiting participants and collecting data. We here provide suggestions regarding how to facilitate future epidemiological data collections in North Macedonia.

Implantable Direct Current Neural Modulation: Theory, Feasibility, and Efficacy

Implantable neuroprostheses such as cochlear implants, deep brain stimulators, spinal cord stimulators, and retinal implants use charge-balanced alternating current (AC) pulses to recover delivered charge and thus mitigate toxicity from electrochemical reactions occurring at the metal-tissue interface. At low pulse rates, these short duration pulses have the effect of evoking spikes in neural tissue in a phase-locked fashion. When the therapeutic goal is to suppress neural activity, implants typically work indirectly by delivering excitation to populations of neurons that then inhibit the target neurons, or by delivering very high pulse rates that suffer from a number of undesirable side effects. Direct current (DC) neural modulation is an alternative methodology that can directly modulate extracellular membrane potential. This neuromodulation paradigm can excite or inhibit neurons in a graded fashion while maintaining their stochastic firing patterns. DC can also sensitize or desensitize neurons to input. When applied to a population of neurons, DC can modulate synaptic connectivity. Because DC delivered to metal electrodes inherently violates safe charge injection criteria, its use has not been explored for practical applicability of DC-based neural implants. Recently, several new technologies and strategies have been proposed that address this safety criteria and deliver ionic-based direct current (iDC). This, along with the increased understanding of the mechanisms behind the transcutaneous DC-based modulation of neural targets, has caused a resurgence of interest in the interaction between iDC and neural tissue both in the central and the peripheral nervous system. In this review we assess the feasibility of in-vivo iDC delivery as a form of neural modulation. We present the current understanding of DC/neural interaction. We explore the different design methodologies and technologies that attempt to safely deliver iDC to neural tissue and assess the scope of application for direct current modulation as a form of neuroprosthetic treatment in disease. Finally, we examine the safety implications of long duration iDC delivery. We conclude that DC-based neural implants are a promising new modulation technology that could benefit from further chronic safety assessments and a better understanding of the basic biological and biophysical mechanisms that underpin DC-mediated neural modulation.

Training with brain-machine interfaces, visuo-tactile feedback and assisted locomotion improves sensorimotor, visceral, and psychological signs in chronic paraplegic patients

Spinal cord injury (SCI) induces severe deficiencies in sensory-motor and autonomic functions and has a significant negative impact on patients' quality of life. There is currently no systematic rehabilitation technique assuring recovery of the neurological impairments caused by a complete SCI. Here, we report significant clinical improvement in a group of seven chronic SCI patients (six AIS A, one AIS B) following a 28-month, multi-step protocol that combined training with non-invasive brain-machine interfaces, visuo-tactile feedback and assisted locomotion. All patients recovered significant levels of nociceptive sensation below their original SCI (up to 16 dermatomes, average 11 dermatomes), voluntary motor functions (lower-limbs muscle contractions plus multi-joint movements) and partial sensory function for several modalities (proprioception, tactile, pressure, vibration). Patients also recovered partial intestinal, urinary and sexual functions. By the end of the protocol, all patients had their AIS classification upgraded (six from AIS A to C, one from B to C). These improvements translated into significant changes in the patients' quality of life as measured by standardized psychological instruments. Reexamination of one patient that discontinued the protocol after 12 months of training showed that the 16-month break resulted in neurological stagnation and no reclassification. We suggest that our neurorehabilitation protocol, based uniquely on non-invasive technology (therefore necessitating no surgical operation), can become a promising therapy for patients diagnosed with severe paraplegia (AIS A, B), even at the chronic phase of their lesion.

TRADUÇÃO PARA LÍNGUA PORTUGUESA DO DATA SET TRATO URINÁRIO INFERIOR PARA INDIVÍDUOS COM LESÃO MEDULAR

RESUMO Objetivo: traduzir e adaptar para a língua portuguesa o data set do trato urinário inferior para indivíduos com lesão medular proposto pela International Spinal Cord Society e American Spinal Injury Association. Método: constitui-se de um estudo metodológico de tradução de instrumento, com a participação de um grupo de cinco especialistas que participaram das fases de tradução e retrotradução e cinco juízes. O Data set foi traduzido e adaptado segundo as recomendações metodológicas da International Spinal Cord Society e American Spinal Injury Association. Resultados: para a etapa de tradução, 56% das sentenças foram traduzidas com unanimidade pelos três tradutores convidados. Das nove questões que compunham o instrumento apenas quatro apresentaram divergências. Conclusão: obteve-se um instrumento traduzido e culturalmente adaptado para avaliação do trato urinário inferior de pessoas com lesão medular em língua portuguesa, proporcionando a participação brasileira nos estudos multicêntricos internacionais sobre lesão medular.

Description of Urological Surveillance and Urologic Ultrasonography Outcomes in a Cohort of Individuals with Long-Term Spinal Cord Injury

Background: Individuals with spinal cord injury (SCI) have an increased risk of developing urological complications. Therefore, long-term routine urological surveillance is recommended. Objective: To describe urological surveillance in individuals with long-term SCI and to determine factors associated with urologic ultrasonography (UU) outcome. Methods: Wheelchair-dependent individuals with an SCI for 10 years or more were included. A medical assessment was done in 8 participating rehabilitation centers. The International Lower Urinary Tract Function Basic SCI Data Set was used to assess bladder-emptying methods and previous surgical procedures on the urinary tract. We studied urological surveillance: whether participants had routine urological checkups (including UU) and when latest urodynamic study was performed. Latest UU (performed <1 year ago) was retrieved or, when lacking, UU was performed as part of our study. Results: Median time since injury (TSI) was 22.0 years. Overall, 39% of the 282 participants did not have routine urological checkups and 33% never had a urodynamic study performed. UU data (N = 243) revealed dilatation of the upper urinary tract (UUT) in 4.5% of the participants and urinary stones in 5.7%. Abnormal UU outcome was associated with increasing TSI, nontraumatic SCI, and previous surgical bladder or UUT stone removal. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Conclusions: Over one-third of Dutch individuals with long-term SCI did not receive routine urological surveillance. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Further research on the indication and frequency of urological surveillance is recommended.

Implementation of a Standardized Dataset for Collecting Information on Patients With Spinal Cord Injury

Background: Over the last decade, the International Spinal Cord Injury Data Sets project developed a number of International Spinal Cord Injury Data Sets (ISCIDS) that can be used to collect standardized information on patients with SCI. Objective and Methods: The aim of this article is to describe the process of translating the ISCIDS into Dutch and reaching consensus on a Dutch National SCI Data Set (NDD). The interrater reliability of the NDD and implementation of the NDD at eight rehabilitation centers with a specialty in rehabilitation after SCI in the Netherlands are described. Results: NDD was implemented successfully at all eight centers. Some adaptations were made to the ISCIDS, especially to the core data set. The reliability coefficients of the NDD items were at least sufficient (mean kappa per data set ranged between .68 and .91), and mean agreement per data set ranged from 66% to 97%. Experiences from the participating centers were mainly positive as well. The main obstacle for use was thought to be the absence of a link between the local patient files and the national database, which necessitates double data entry. Conclusion: Although the results on interrater reliability are based on a small sample size and the assessment situation is different from the normal clinical situation, this study showed the NDD to be a useful instrument to collect standardized information on patients with SCI in the Netherlands. In the future, a connection between systems or another way to centrally collect the data is recommended to prevent double data entry and to guarantee continuation of administration of the NDD.

Bladder emptying method is the primary determinant of urinary tract infections in patients with spinal cord injury: results from a prospective rehabilitation cohort study

OBJECTIVE

To understand the occurrence of and risk factors for urinary tract infections (UTIs) in patients with spinal cord injury (SCI) undergoing specialized SCI rehabilitation in Switzerland.

PATIENTS AND METHODS

This study used data collected from 369 patients, who participated in a nationwide rehabilitation cohort for SCI in Switzerland between 2013 and 2017. Information on UTIs as well as their potential determinants, including demographics, lesion characteristics, and time-updated data on functional independence and bladder management, was used. Multivariable regression methods were applied to perform a time-updated evaluation of determinants of UTI risk.

RESULTS

The crude incidence rate (IR) of UTIs was 0.55 UTIs per 100 person-days (95% confidence interval [CI] 0.49-0.62), the cumulative IR was 43%, and the median length of stay was 122 days. The bladder emptying method at discharge was largely determined by 28 days after admission. Among those using indwelling or assisted intermittent catheterization (IC), the likelihood of self-IC at discharge was positively related to the level of self-care independence, negatively related to age at injury, and lower in women than men. Catheter users consistently had higher adjusted IRs for UTI than spontaneous voiders. The IR ratios were: indwelling catheter: 5.97 (95% CI 2.63-13.57); assisted IC: 6.05 (95% CI 2.63-13.94); self-IC: 5.16 (95% CI 2.31-11.52); test for differences across catheter groups: P = 0.82. Lesion severity and previous UTI had additional but smaller effect sizes.

CONCLUSIONS

Bladder emptying method was identified as the main risk factor for UTI in patients with SCI. As spontaneous voiders had the lowest UTI rate, further research is warranted to reduce voiding dysfunction, for instance using neuromodulation procedures.

Pelvic organ prolapse and urogynecological assessment in women with spinal cord injury

STUDY DESIGN

Observational cross-sectional study.

OBJECTIVES

Due to weakened pelvic floor muscles, the risk of pelvic organ prolapse (POP) may increase after a spinal cord injury (SCI); hence, the aim of this study was to investigate the occurrence of POP after SCI and to evaluate the need for urogynecological consultations offered to women with SCI.

SETTING

Clinic for Spinal Cord Injuries, Rigshospitalet, Denmark.

METHODS

Women with SCI who visited our SCI-clinic during January 2013-January 2018 were offered a specialized urogynecological consultation. Any symptoms of POP, urinary/fecal incontinence, or bladder/bowel emptying problems were registered, and POP was classified according to the POP quantification system during a pelvic examination. Differences in baseline characteristics between women with POP stage 0-1 and POP stage ≥2 were investigated.

RESULTS

A total of 98 women were included in the study. Fourteen women (14%) reported POP symptoms and 21 women (21%) had anatomical POP stage ≥2. The group with POP stage ≥2 had a significantly higher age, higher parity, more with vaginal delivery, and more postmenopausal women, but the groups did not differ on median time after injury, neurological level, and completeness of injury. A total of 71% experienced urinary incontinence, 27% experienced fecal incontinence, 63% experienced bladder emptying problems, and 70% experienced bowel emptying problems. Consequently, 65% received treatment.

CONCLUSIONS

Women with SCI are not in increased risk of developing anatomical POP. Nonetheless, the high occurrence of other urogynecological issues and the high treatment-rate supports the need for specialized urogynecological consultations offered to women with SCI.

Electronic medical record: data collection and reporting for spinal cord injury

STUDY DESIGN

Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic.

OBJECTIVES

To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally.

SETTING

Denmark and United States of America.

METHODS

The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting.

RESULTS

The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient's chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2).

CONCLUSIONS

The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide.

SPONSORSHIP

Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

International Spinal Cord Injury Lower Urinary Tract Function Basic Data Set (version 2.0)

STUDY DESIGN

Revision, review, and presentation of the International Spinal Cord Injury (SCI) Lower Urinary Tract (LUT) Function Basic Data Set (version 2.0).

OBJECTIVES

Describe the revision and review and present the data set.

SETTING

International.

METHODS

The first version of the data set was revised according to new knowledge and suggestions. The review included International SCI Data Sets Committee, American Spinal Injury Association (ASIA) board, International Spinal Cord Society (ISCoS) executive and scientific committees, major organizations, and interested individuals. The data set was also on ASIA and ISCoS websites. All replies were answered and appropriate adjustments made. Finally, the data set was endorsed by ASIA board, and ISCoS executive and scientific committees.

RESULTS

Among revisions are adoptions of new terminology by the International Continence Society. For most variables, advice for collection of information from pediatric patients stated. For the variable 'Bladder emptying', is in the data collection form to the response category 'Normal voiding' expanded. 'Sacral Anterior Root Stimulator' is deleted as response category. For the variable 'Any involuntary urine leakage (incontinence) within the last 4 weeks' 'last 4 weeks' has replaced 'last 3 months'. The response categories have been adjusted to: 'Daily', 'Once or more per week (but not daily)', 'Less than once per week', 'Never', 'Not applicable' and 'Unknown'. For the variable 'Any drugs for the urinary tract within the last four weeks' 'last four weeks' has replaced 'last year'.

CONCLUSIONS

The International SCI LUT Function Basic Data Set (version 2.0) with its complete syllabus is available from http://www.iscos.org.uk/international-sci-data-sets.

Effect of spinal anterior root stimulation and sacral deafferentation on bladder and sexual dysfunction in spinal cord injury

BACKGROUND

Spinal cord injury (SCI) is a highly devastating injury with a variety of complications; among them are neurogenic bladder, bowel, and sexual dysfunction. We aimed to evaluate the effect of sacral anterior root stimulation with sacral deafferentation (SARS-SDAF) on neurogenic bladder and sexual dysfunction in a large well-defined spinal cord injury cohort.

METHODS

In the manner of cross-sectional study, subjects undergone SARS-SDAF between September 1986 and July 2011 answered a questionnaire concerning conditions before and after surgery in the department of Neuro-Urology, Bad Wildungen, Germany.

RESULTS

In total 287 of 587 subjects were analyzed. Median age was 49 years (range 19-80), median time from SCI to surgery was 10 years (range 0-49), and from surgery to follow-up 13 years (range 1-25). Of the analyzed subjects, 100% of both gender used SARS for bladder emptying. On the visual analogue scale (VAS) ranging from 0 to 10 (best), satisfaction with SARS-SDAF was 10 concerning bladder emptying, however 5 and 8 regarding sexual performance, for female and male users, respectively. Baseline and follow-up comparison showed a decline in self-intermittent catheterization (p < 0.0001), partial catheterization by attendant (p = 0.0125), complete catheterization and suprapubic catheterization (p < 0.0001), transurethral catheterization (p < 0.0011), and fewer cases of involuntary urine leakage (p < 0.0001).

CONCLUSIONS

The SARS-SDAF is a beneficial multi-potential treatment method with simultaneous positive effect on multi-organ dysfunction among SCI subjects.

Progress of the Dutch Spinal Cord Injury Database: Completeness of Database and Profile of Patients Admitted for Inpatient Rehabilitation in 2015

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.

Facilitators and Barriers to International Collaboration in Spinal Cord Injury: Results from a Survey of Clinicians and Researchers

International collaboration in spinal cord injury (SCI) research is necessary to overcome the challenges often encountered by clinicians and researchers, including participant recruitment, high cost, and the need for specialized expertise. However, international collaboration poses its own obstacles. The objective of this study was to conduct an international online survey to assess barriers and facilitators to international SCI clinical research, potential initiatives to facilitate future collaborations, and the use of SCI-specific data sets and standards. Results were analyzed using descriptive statistics. Of 364 total respondents, 213 completed the survey, with the majority of these participants based in North America (38%), Asia (22%), Europe (18%), and Oceania (16%). Over half had more than 10 years of experience in SCI research or clinical practice (57%) and 60% had previous experience with international collaborations. Funding was identified as a top barrier (82%), a facilitator (93%), and a proposed future initiative (97%). Communication and technology were also identified as strong facilitators and proposed future initiatives. The International Standards for Neurological Classification of SCI were used by 69% of participants, the International Standards to document remaining Autonomic Function after SCI by 13% of participants, and the International SCI Data Sets by 45% of participants. As the need for international collaborations in SCI research increases, it is important to identify how clinicians and researchers can be supported by SCI consumer and professional organizations, funders, and networks. Furthermore, unique solutions to overcome modifiable barriers and creation of new facilitators are also needed.

Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury

OBJECTIVE

Locomotor training (LT) as a therapeutic intervention following spinal cord injury (SCI) is an effective rehabilitation strategy for improving motor outcomes, but its impact on non-locomotor functions is unknown. Given recent results of our labs' pre-clinical animal SCI LT studies and existing overlap of lumbosacral spinal circuitries controlling pelvic-visceral and locomotor functions, we addressed whether LT can improve bladder, bowel and sexual function in humans at chronic SCI time-points (> two years post-injury).

STUDY DESIGN

Prospective cohort study; pilot trial with small sample size.

METHODS

Eight SCI research participants who were undergoing 80 daily one-hour sessions of LT on a treadmill using body-weight support, or one-hour of LT and stand training on alternate days, as part of another research study conducted at the Kentucky Spinal Cord Injury Research Center, University of Louisville, were enrolled in this pilot trial. Urodynamic assessments were performed and International Data Set questionnaire forms completed for bladder, bowel and sexual functions at pre-and post-training time points. Four usual care (non-trained; regular at-home routine) research participants were also enrolled in this study and had the same assessments collected twice, at least 3 months apart.

RESULTS

Filling cystometry documented significant increases in bladder capacity, voiding efficiency and detrusor contraction time as well as significant decreases in voiding pressure post-training relative to baseline. Questionnaires revealed a decrease in the frequency of nocturia and urinary incontinence for several research participants as well as a significant decrease in time required for defecation and a significant increase in sexual desire post-training. No significant differences were found for usual care research participants.

CONCLUSIONS

These results suggest that an appropriate level of sensory information provided to the spinal cord, generated through task-specific stepping and/or loading, can positively benefit the neural circuitries controlling urogenital and bowel functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03036527.

Transient Hypertension after Spinal Cord Injury Leads to Cerebrovascular Endothelial Dysfunction and Fibrosis

We aimed to create a clinically relevant pre-clinical model of transient hypertension, and then evaluate the pathophysiological cerebrovascular processes resulting from this novel stimulus, which has recently been epidemiologically linked to cerebrovascular disease. We first developed a clinically relevant model of transient hypertension, secondary to induced autonomic dysreflexia after spinal cord injury and demonstrated that in both patients and rats, this stimulus leads to drastic acute cerebral hyperperfusion. For this, iatrogenic urodynamic filling/penile vibrostimulation was completed while measuring beat-by-beat blood pressure and cerebral blood flow (CBF) in patients. We then developed a rodent model mimicking the clinical reality by performing colorectal distention (to induce autonomic dysreflexia) using pre-clinical beat-by-beat blood pressure and CBF assessments. We then performed colorectal distension in rats for four weeks (6x/day) to evaluate the long-term cerebrovascular consequences of transient hypertension. Outcome measures included middle cerebral artery endothelial function, remodeling, profibrosis and perivascular innervation; measured via pressure myography, immunohistochemistry, molecular biology, and magnetic resonance imaging. Our model demonstrates that chronic repetitive cerebral hyperperfusion secondary to transient hypertension because of autonomic dysreflexia: (1) impairs cerebrovascular endothelial function; (2) leads to profibrotic cerebrovascular stiffening characterized by reduced distensibility and increased collagen deposition; and (3) reduces perivascular sympathetic cerebrovascular innervation. These changes did not occur concurrent to hallmark cerebrovascular changes from chronic steady-state hypertension, such as hypertrophic inward remodeling, or reduced CBF. Chronic exposure to repetitive transient hypertension after spinal cord injury leads to diverse cerebrovascular impairment that appears to be unique pathophysiology compared with steady-state hypertension in non-spinal cord injured models.

Alarming blood pressure changes during routine bladder emptying in a woman with cervical spinal cord injury

INTRODUCTION

Many individuals with high-level spinal cord injury (SCI) experience secondary conditions such as autonomic dysreflexia (AD), which is a potentially life-threatening condition comprising transient episodes of hypertension up to 300 mmHg. AD may be accompanied by symptoms and signs such as headache, flushing, and sweating. Delay in AD recognition and management is associated with increased incidence of cardiovascular events and disease. As it is commonly triggered by bladder distension, AD continues to be a major concern for individuals living with SCI, both on a daily basis and in the long-term.

CASE PRESENTATION

A 58-year-old woman with C3 AIS B SCI presented with low resting blood pressure (BP) at 100/64 mmHg. She reported frequent episodes of AD that were most commonly attributed to urinary bladder filling. During our testing session, her systolic BP rose to 130 mmHg, at which point her care aide stepped in to utilize the Credé maneuver, which was part of her daily routine for bladder emptying. Application of suprapubic pressure further elevated her systolic BP to 230 mmHg. Throughout the episode of AD, the participant experienced a pounding headache and erythema above the LOI.

DISCUSSION

Clinical guidelines for bladder management after SCI recommend avoiding the Credé maneuver due to potential complications such as hernia or bruising. This current case report demonstrates the additional risk of inducing AD and dangerously high BP elevation.

Body System Effects of a Multi-Modal Training Program Targeting Chronic, Motor Complete Thoracic Spinal Cord Injury

The safety and efficacy of pharmacological and cellular transplantation strategies are currently being evaluated in people with spinal cord injury (SCI). In studies of people with chronic SCIs, it is thought that functional recovery will be best achieved when drug or cell therapies are combined with rehabilitation protocols. However, any functional recovery attributed to the therapy may be confounded by the conditioned state of the body and by training-induced effects on neuroplasticity. For this reason, we sought to investigate the effects of a multi-modal training program on several body systems. The training program included body-weight-supported treadmill training for locomotion, circuit resistance training for upper body conditioning, functional electrical stimulation for activation of sublesional muscles, and wheelchair skills training for overall mobility. Eight participants with chronic, thoracic-level, motor-complete SCI completed the 12-week training program. After 12 weeks, upper extremity muscular strength improved significantly for all participants, and some participants experienced improvements in function, which may be explained by increased strength. Neurological function did not change. Changes in pain and spasticity were highly variable between participants. This is the first demonstration of the effect of this combination of four training modalities. However, balancing participant and study-site burden with capturing meaningful outcome measures is also an important consideration.

Impact of bladder, bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

OBJECTIVE

The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

METHODS

Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

RESULTS

Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

CONCLUSION

Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

Safety of Autologous Human Schwann Cell Transplantation in Subacute Thoracic Spinal Cord Injury

The rationale for implantation of autologous human Schwann cells (SCs) in persons with subacute spinal cord injury (SCI) is based on evidence that transplanted SCs are neuroprotective, support local axonal plasticity, and are capable of myelinating axons. A Phase I clinical trial was conducted to evaluate the safety of autologous human SC transplantation into the injury epicenter of six subjects with subacute SCI. The trial was an open-label, unblinded, non-randomized, non-placebo controlled study with a dose escalation design and standard medical rehabilitation. Participants were paraplegics with neurologically complete, trauma-induced spinal lesions. Autologous SCs were cultured in vitro from a sural nerve harvested from each participant and injected into the epicenter of the spinal lesion. Outcome measures for safety were protocol compliance, feasibility, adverse events, stability of neurological level, absence of detectable mass lesion, and the emergence of clinically significant neuropathic pain or muscle spasticity no greater than expected for a natural course cohort. One year post-transplantation, there were no surgical, medical, or neurological complications to indicate that the timing or procedure for the cell transplantation was unsafe. There were no adverse events or serious adverse events related to the cell therapy. There was no evidence of additional spinal cord damage, mass lesion, or syrinx formation. We conclude that it is feasible to identify eligible candidates, appropriately obtain informed consent, perform a peripheral nerve harvest to obtain SCs within 5-30 days of injury, and perform an intra-spinal transplantation of highly purified autologous SCs within 4-7 weeks of injury.

Bladder-emptying methods, neurogenic lower urinary tract dysfunction and impact on quality of life in people with long-term spinal cord injury

OBJECTIVES

To describe bladder-emptying methods used by people with long-term spinal cord injury (SCI) and to determine usage differences in relation to time since injury, sex, lesion level and completeness of lesion. Furthermore, to evaluate the relationship between bladder-emptying methods and the impact of neurogenic lower urinary tract dysfunction (NLUTD) on quality of life (QoL).

DESIGN

Cross-sectional multicenter study.

SETTING

Dutch community.

PARTICIPANTS

Persons dependent on wheelchairs (N = 282) with traumatic or non-traumatic SCI for ≥10 years and age at injury of 18-35 years.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The International Lower Urinary Tract Function Basic SCI Data Set and the Short-Form Qualiveen (SF-Qualiveen).

RESULTS

Median time since injury was 22.0 years (IQR: 16.8-30.3). Clean intermittent catheterization (CIC) was most commonly used (42.6%). Longer time since injury was associated with fewer continent urinary diversions and more transurethral catheter use. Transurethral catheter use and continent urinary diversions were more prevalent among women. Participants with tetraplegia were more likely to use reflex voiding or a suprapubic catheter, and participants with paraplegia were more likely to use CIC. Transurethral catheter users reported the highest impact of NLUTD on quality of life (SF-Qualiveen score: 1.9; SD = 0.8). Participants with a continent urinary diversion reported the lowest impact (SF-Qualiveen score: 0.9; SD = 0.6). Higher age and indwelling catheter use versus CIC were associated with a higher impact of NLUTD on QoL.

CONCLUSIONS

CIC is the most common bladder-emptying method in Dutch people with long-term SCI. Clinicians should be aware of the impact of NLUTD on QoL, especially for those using an indwelling catheter.

The management of neurogenic lower urinary tract dysfunction after spinal cord injury

The management of patients with neurogenic bladder has changed substantially over the past decades. Obtaining balanced lower urinary tract function has become possible in most patients, although, urological complications remain among the most serious complications these patients are likely to have and, even today, these can have a negative effect on quality of life. To this extent, patients with spinal cord injury (SCI) are likely to develop neurogenic bladder, and data are available on most aspects of neurogenic bladder in these patients. Data on physiology and pathophysiology form the basis of our understanding of patients' symptoms, and also provide a basis for the management of these patients. The use of conservative, and/or more invasive treatment measures, their complications and measures to prevent these complications, are all important clinical aspects that merit discussion. Considerable progress has been made in the urological management of patients with SCI over the past decades, but opportunities remain to make diagnosis more accurate and therapy more successful.

Standardization of Data for Clinical Use and Research in Spinal Cord Injury

Increased survival after spinal cord injury (SCI) worldwide has enhanced the need for quality data that can be compared and shared between centers, countries, as well as across research studies, to better understand how best to prevent and treat SCI. Such data should be standardized and be able to be uniformly collected at any SCI center or within any SCI study. Standardization will make it possible to collect information from larger SCI populations for multi-center research studies. With this aim, the international SCI community has obtained consensus regarding the best available data and measures for use in SCI clinical practice and research. Reporting of SCI data is likewise standardized. Data elements are continuously updated and developed using an open and transparent process. There are ongoing internal, as well as external review processes, where all interested parties are encouraged to participate. The purpose of this review paper is to provide an overview of the initiatives to standardize data including the International Spinal Cord Society's International SCI Data Sets and the National Institutes of Health, National Institute of Neurological Disorders and Stroke Common Data Elements Project within SCI and discuss future opportunities.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury

OBJECTIVES

To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling.

DESIGN

Cross-sectional observational study.

SETTING

A Spinal Cord Injury Model System, with additional participants recruited from other sites.

PARTICIPANTS

Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling.

RESULTS

Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake.

CONCLUSIONS

These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Reduction in Bladder-Related Autonomic Dysreflexia after OnabotulinumtoxinA Treatment in Spinal Cord Injury

Bladder-related events, including neurogenic detrusor overactivity, are the leading cause of autonomic dysreflexia in spinal cord injured individuals. Self-reported autonomic dysreflexia is reduced following onabotulinumtoxinA treatment for neurogenic detrusor overactivity; however, none of these trials have assessed autonomic dysreflexia events using the clinical cutoff of an increase in systolic blood pressure ≥20 mm Hg. This study used a prospective, open-labelled design from 2013 to 2014 to quantitatively assess the efficacy of one cycle 200 U intradetrusor-injected onabotulinumtoxinA (20 sites) on reducing the severity and frequency of bladder-related autonomic dysreflexia events and improving quality of life. Twelve men and five women with chronic, traumatic spinal cord injuries at or above the sixth thoracic level, and concomitant autonomic dysreflexia and neurogenic detrusor overactivity, underwent blood pressure monitoring during urodynamics and over a 24 h period using ambulatory blood pressure monitoring pre- and 1 month post-treatment. Post-onabotulinumtoxinA, autonomic dysreflexia severity was reduced during urodynamics (systolic blood pressure increase: 42 ± 23 mm Hg vs. 20 ± 10 mm Hg, p < 0.001) and during bladder-related events across the 24 h period (systolic blood pressure increase: 49 ± 2 mm Hg vs. 26 ± 22 mm Hg, p = 0.004). Frequency of 24 h bladder-related autonomic dysreflexia events was also decreased post-onabotulinumtoxinA (4 ± 2 events vs. 1 ± 1 events, p < 0.001). Autonomic dysreflexia and incontinence quality of life indices were also improved post-onabotulinumtoxinA (p < 0.05). Intradetrusor injections of onabotulinumtoxinA for the management of neurogenic detrusor overactivity in individuals with high level spinal cord injuries decreased the severity and frequency of bladder-related episodes of autonomic dysreflexia, and improved bladder function and quality of life.

Common data elements for spinal cord injury clinical research: a National Institute for Neurological Disorders and Stroke project

OBJECTIVES

To develop a comprehensive set of common data elements (CDEs), data definitions, case report forms and guidelines for use in spinal cord injury (SCI) clinical research, as part of the CDE project at the National Institute of Neurological Disorders and Stroke (NINDS) of the US National Institutes of Health.

SETTING

International Working Groups.

METHODS

Nine working groups composed of international experts reviewed existing CDEs and instruments, created new elements when needed and provided recommendations for SCI clinical research. The project was carried out in collaboration with and cross-referenced to development of the International Spinal Cord Society (ISCoS) International SCI Data Sets. The recommendations were compiled, subjected to internal review and posted online for external public comment. The final version was reviewed by all working groups and the NINDS CDE team before release.

RESULTS

The NINDS SCI CDEs and supporting documents are publically available on the NINDS CDE website and the ISCoS website. The CDEs span the continuum of SCI care and the full range of domains of the International Classification of Functioning, Disability and Health.

CONCLUSION

Widespread use of CDEs can facilitate SCI clinical research and trial design, data sharing and retrospective analyses. Continued international collaboration will enable consistent data collection and reporting, and will help ensure that the data elements are updated, reviewed and broadcast as additional evidence is obtained.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review

STUDY DESIGN

This is a systematic review.

OBJECTIVE

The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD).

SETTING

This study was conducted in an international setting.

METHODS

A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded.

RESULTS

Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling.

CONCLUSION

The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.